**11. Complications**

addition, patient's experienced a significant improvement in the total loss of extension from an average of 80 to 10°. Another study prospectively evaluated 90 patients undergoing a fasciectomy for a 60-degree or more deficit in total active extension and reported 81% patient satisfaction with function, 87% reaching functional ROM, and significantly improved DASH

Further analysis of surgical treatment has lead authors to identify certain characteristic associated with better outcomes. Patients with MCP contractures are more likely to achieve full intra-operative correction (Donaldson). However, correction of PIP contractures has a stronger correlation to improved hand function when compared with correction of the MCP joint [77]. Surgical treatment has focused on PIP contractures to maximize intra-operative correction and improve functional outcomes. Surgeons have tried releasing the PIP capsule with a fasciectomy to improve PIP correction, but there is no strong data to support whether it is effective [78]. Zyluk et al. reported younger patients had a significantly greater functional improvement after surgery as measured by the DASH score [75]. Studies have also cited the extent of preoperative deformity, incomplete correction, and multiple involved digits as fac-

Despite multiple studies reporting good outcomes after surgery, there are limited randomized studies comparing outcomes after different operative techniques. Ullah et al. found no difference in ROM or recurrence in 79 patients randomized to either direct closure with z-plasty or firebreak skin grafting after a fasciectomy, however, patients with skin grafting had an increased incidence of hypoesthesia [81]. Van Rijssen et al. randomized patients to percutaneous needle fasciotomy and limited fasciectomy and reported the PNF group was significantly higher recurrence rate (76.8 vs. 20.9%, p < 0.001) and lower VAS satisfaction scores (6.2 vs. 8.3, p < 0.001) [62]. Further prospective, randomized studies reporting functional outcomes, complications, and recurrence rates are necessary to recommend any

Recurrence of a Dupuytren's contracture is a common event even after successful initial treatment. A systematic review analyzed 51 studies and reported recurrence rates ranged from 0 to 71% [82]. Furthermore, recurrence rates are difficult to assess as there is considerable variation in the criteria used to define recurrence. Some authors report the presence of any diseased tissue after treatment while others include only contractures necessitating re-operation. More recently, studies have tended to define recurrence as a 20–30° loss of extension in a successfully treated digit. A recent randomized study defined recurrence as a 20° reduction of total passive extension in a successfully treated digit and reported a 20.9% 5-year recurrence rate

Multiple studies have focused on identifying factors which may predispose patients to recurrence. The dramatic variability of recurrence rates may be due to the heterogeneity of the presentation of Dupuytren's itself, as many patients may have more aggressive biology associated with "Dupuytren's diathesis", whereas others may have more mild disease. Dupuytren

tors affecting post-operative functional outcomes [75, 78–80].

scores at 1 year follow up [76].

74 Essentials of Hand Surgery

surgical procedure.

**10. Recurrence**

after limited fasciectomy [62].

Despite good outcomes after surgical treatment of Dupuytren's contractures surgery is not without complications. A 20 year systematic review of complications by Denkler et al. reported an average major complication risk of 15% with complication rates ranging from 3.6 to 39.1% [86]. Specific complications after limited fasciectomy included the following: wound healing problems, 22.9%; flare reaction, 9.9%; complex region pain syndrome, 5.5%; nerve injury, 3.4%; infection, 2.4%; hematoma, 2.1%; and digit artery injury, 2%. Severe complications include tendon rupture or loss of the digit but are extremely rare. Patients with severe flexion contractures are more at risk of experiencing a complication [87]. Smoking and diabetes, however, has not been identified as an increased risk factor for wound healing problems after surgery [88]. Patients undergoing revision surgery for recurrence are most at risk for complications, especially neurovascular injuries due to scar tissue and loss of anatomic landmarks. Neurovascular injuries have been reported as high as 10 times more common in revision surgeries for recurrence [86].
